Effect of gabapentin pretreatment on propofol consumption,hemodynamic variables,and postoperative pain relief in breast cancer surgery

Study objectiveGabapentin is an inhibitory neurotransmitter of the central nervous system. This prospective randomized double-blind study was conducted to evaluate the effects of gabapentin on intraoperative propofol requirements, hemodynamic variables, and postoperative pain relief in breast cancer patients.Materials and methodsForty adult females of the American Society of Anesthesiologists (ASA) Grade I-II physical status, undergoing total mastectomy for breast cancer were included. Patients were randomly allocated into two groups. Two hours prior to surgery the gabapentin group received gabapentin 600 mg and the control group received placebo. Anesthesia was induced with intravenous fentanyl, propofol, and vecuronium, and maintained with propofol infusion titrated according to the bispectral index. Postoperative analgesia was provided with intramuscular diclofenac sodium and intravenous morphine on demand.ResultsThe intraoperative propofol consumption was significantly less in the gabapentin group as compared with the control group (p = 0.009), whereas there was no difference in fentanyl and vecuronium requirements. Patients in the gabapentin group had lower pain scores at 30 minutes, 1 hour, and 2 hours postoperatively (p < 0.001). The postoperative morphine consumption was also less in the gabapentin group compared with the control group (p = 0.006). No significant adverse effects were noticeable.ConclusionPreoperative administration of gabapentin reduced intraoperative propofol requirements and postoperative analgesic consumption in breast cancer patients undergoing total mastectomy.     

A comparison of epidural magnesium and/or morphine with bupivacaine for postoperative analgesia after cesarean section

BackgroundMagnesium can potentiate the antinociceptive effect of morphine. This prospective randomized double-blinded study was undertaken to establish the analgesic effect of adding magnesium to epidural morphine during cesarean section.MethodsTwo hundred patients undergoing cesarean section under combined spinal–epidural anesthesia were recruited. After administration of intrathecal bupivacaine 10 mg, patients were randomly assigned to receive one of four epidural study solutions: 0.1% bupivacaine 10 mL (Group B); 0.1% bupivacaine 10 mL and morphine 1.5 mg (Group B+Mor); 0.1% bupivacaine 10 mL and magnesium 500 mg (Group B+Mg); or 0.1% bupivacaine 10 mL morphine 1.5 mg and magnesium 500 mg (Group B+Mor+Mg). The primary outcome was the area under the curve for visual analog scale pain scores during 36 h postoperatively. Secondary outcomes included time to the use of rescue analgesics, patient satisfaction and side effects.ResultsPatients in Group B+Mor+Mg had lower for pain scores and area under the curve pain scores both at rest and on movement, increased time for first analgesic request, and increased satisfaction score at 24 h after surgery.ConclusionAddition of magnesium 500 mg and morphine 1.5 mg to epidural 0.1% bupivacaine 10 mL reduced postoperative pain compared with addition of morphine or magnesium alone or no additive.     

A Repeat Dose of Perioperative Dexamethasone Can Effectively Reduce Pain,Opioid Requirement,Time to Ambulation,and In-Hospital Stay After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial

BackgroundThe ideal dose of intravenous glucocorticoids to control pain in total hip arthroplasty (THA) remains unclear. This randomized controlled trial compared postoperative pain and tramadol requirement in patients undergoing unilateral primary THA who received one versus two perioperative doses of dexamethasone.MethodsPatients consented to undergo blinded, simple randomization to either one (at anesthetic induction [1D-group]: 54 patients) or two (with an additional dose 8 hours after surgery [2D-group]: 61 patients) perioperative doses of 8-mg intravenous dexamethasone. Pain was evaluated with visual analog scale at 8, 16, and 24 hours postoperatively and with tramadol requirement. The secondary outcomes included postoperative nausea and vomiting, time to ambulation, and length of stay.ResultsAge (mean, 66 ± 13 years), body mass index (mean, 29 ± 5), gender (60% female), and history of diabetes were similar between groups (P >.05). Pain was higher at 16 (4 [interquartile range {IQR} 3-5] vs 2 [IQR 1-3]; P <.001) and 24 (2.5 [IQR 2-3] vs 1 [IQR 0-1] P <.001) hours postoperatively in the 1D-group patients. 1D-group patients had significantly more tramadol consumption (50 [IQR 50-100] vs 0 [IQR 0-50]; P = .01), as well as postoperative nausea and vomiting (18 [33.3%] vs 5 [8.2%]; P = .001). Fifty-five (90%) patients in the 2D-group and 32 (59%) in the 1D-group ambulated on postoperative day 0 (P = .0002). Fifty-eight (95%) patients in the 2D-group and 37 (68%) in the 1D-group were discharged on postoperative day 1 (P = .0002).ConclusionAn additional dose of dexamethasone at 8 hours postoperatively significantly reduced pain, tramadol consumption, time to ambulation, and length of stay after primary THA.     

Bupivacaine-soaked absorbable gelatin sponges in caesarean section wounds: effect on postoperative pain,analgesic requirement and haemodynamic profile

BackgroundPain is a common distressing adverse effect in the early postoperative period following caesarean section. The aim of this study was to investigate the effect on postoperative pain, analgesic requirement and haemodynamic profile of placing a suprafacial bupivacaine-soaked absorbable gelatin sponge in the caesarean section wound.MethodsA total of 164 healthy patients scheduled to undergo general anaesthesia for elective caesarean section were randomised to a study group (n=81) or a control group (n=83). In the study group, a bupivacaine-soaked absorbable gelatin sponge was placed subcutaneously in the caesarean section wound. Intramuscular diclofenac 75 mg was given to all patients at 8-h intervals during the first 24 h. Postoperatively, visual analogue scale pain scores, requirement for pethidine and diclofenac and changes in blood pressure and heart rate were compared between groups.ResultsPain scores were lower in the study group compared to the control group at all assessments (P <0.001). During the first eight hours after surgery, fewer patients in the study group required rescue pethidine compared with the control group (4 vs. 33, P <0.001). In the study group, total opioid and diclofenac consumption was lower (P <0.001), and blood pressure and heart rate were lower (P <0.001) compared to the control group.ConclusionSuprafascial wound placement of a bupivacaine-soaked absorbable gelatin sponge improved postoperative analgesia and decreased opioid consumption following caesarean section.     

PCA after subarachnoid block for cesarean section

We studied the pain control, narcotic side effects, and PCA utilization with intravenous PCA morphine during 24 hours post cesarean section period. Fifty-two consecutive women were included in the study. Each received subarachnoid block with hyperbaric bupivacain with addition of fentanyl. After surgery, the patient received diclofenac suppository and IV-PCA commenced in the recovery room. Severity of pain and sedation was assessed hourly, and maximum pain and sedation scores for each 6-hour period were recorded. Two-third of the patients felt mild to moderate pain during transition from spinal analgesia to IV-PCA. Pain severity steadily improved during four 6-hour periods (p-value <0.001). Highest mean sedation score was noticed during the third six-hour postoperative period. Mean morphine consumption was 50 mg.The ratio between number of time PCA activated and dose received and pain score helped in managing the postoperative pain. Morphine IV-PCA, adequately replaces post cesarean section spinal (bupivacain-fentanyl) analgesia with fewer side effects.     

Postoperative Analgesic Efficacy of Different Volumes and Masses of Ropivacaine in Posterior Brachial Plexus Block

Background and objectivesThe efficacy of posterior brachial plexus block for shoulder surgeries is demonstrated by different authors. However, there is no consensus on the ideal mass and volume of local anesthetic to be employed. The objetive of this study was to compare different volumes and masses of ropivacaine in posterior brachial plexus block in arthroscopic surgeries of the shoulder.MethodSixty patients > 18 years, physical status ASA I and II, scheduled for unilateral arthroscopic surgeries of the shoulder were randomly placed in three groups: A (10 mL to 0.5%), B (20 mL to 0.5%), C (5 mL to 1%). The block was performed with a 22G needle of 100 mm connected to neurostimulator, in a point 3 cm lateral to the midpoint of C6 and C7 interspace, being injected the solution corresponding to each group. The postoperative pain was evaluated at the recovery room and within the first 24 hours of the postoperative period. The groups were compared on length of time until the first complaint of pain, visual numeric scale (VNS) score and morphine consumption within the first 24 hours.ResultsThere was no statistically significant difference between the three groups related to age, weight and height. There was no difference in length of time until the first complaint of pain, VNS scores over three and morphine consumption in the postoperative period between the groups.ConclusionsThis study concluded that 5 mL of 1% ropivacaine promoted analgesic efficacy similar to 10 mL or 20 mL of 0.5% ropivacaine in the posterior brachial plexus block using neurostimulator.     

Combination of oral clonidine and intravenous low-dose ketamine reduces the consumption of postoperative patient-controlled analgesia morphine after spine surgery

ObjectiveBecause ketamine, clonidine, and morphine modulate nociceptive pain, coadministration of these drugs would augment the activity of postoperative analgesic drugs. The purpose of this study was to evaluate the effects of coadministration of ketamine and clonidine on postoperative morphine consumption in patients after spine surgery.MethodsThe patients undergoing spine surgery were allocated randomly to one of the four study groups, which are as follows: group M (n = 12), intravenously (IV) administered patient-controlled analgesia (PCA) morphine alone; group MK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine; group MC (n = 13), IV-PCA morphine plus oral clonidine premedication; group MCK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine and clonidine premedication. The patients in the MC and MCK groups received 4 μg/kg clonidine orally, whereas those in the MK and MCK groups received IV bolus of ketamine (10 mg) at a rate of 2 mg/kg/hour during anesthesia. Patients were arranged to use IV-PCA mode for administration of drugs, which was programmed to deliver a bolus dose of 2-mg morphine (groups M and MC), or boluses of 2-mg morphine and 2-mg ketamine (groups MK and MCK). Scores of visual analog scale (VAS) for pain, morphine requirement, vital signs, nausea, sedation, and other side effects were followed up to 60 hours after surgery.ResultsAlthough there were significant differences in VAS pain scores at rest 24–48 hours after the surgery, the VAS pain score at movement was similar among the groups. The number of PCA request and cumulative morphine requirement were significantly lower in the MCK group than in the M group.ConclusionThis study results show that the administration of perioperative low-dose ketamine combined with clonidine premedication could reduce the consumption of postoperative PCA morphine following spine surgery.     

Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundThis study examined whether pericapsular nerve group (PENG) block combined with local infiltration analgesia (LIA) could improve pain management and functional recovery after total hip arthroplasty.MethodsAll patients were randomly assigned to receive PENG block combined with LIA (PENG group) or sham PENG block and LIA (Sham group). The primary outcome was cumulative morphine consumption within 24 hours after surgery. Secondary outcomes were pain scores on a visual analog scale (VAS); time to first rescue analgesia; cumulative morphine consumption during hospitalization; intraoperative consumption of opioids; postoperative recovery; and postoperative complications.ResultsPENG patients consumed significantly less morphine within the first 24 hours and throughout hospitalization and smaller amounts of intraoperative opioids. There were significantly lower pain scores at rest and during motion within 24 hours in PENG patients. PENG patients took significantly longer until the first rescue analgesia and showed significantly better postoperative rehabilitation. However, the absolute change in morphine consumption and VAS scores did not exceed the reported minimal clinically important differences (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement). The two groups showed no difference in quadriceps muscle strength and postoperative complications.ConclusionPENG block combined with LIA could improve postoperative pain relief, reduce opioid use, and enhance recovery in total hip arthroplasty patients, without weakening the quadriceps muscle strength. This work justifies further trials to examine the safety and efficacy of this block and to explore maximal effective volume of local anesthetic for motor-sparing PENG block.     

Analgesic requirements and postoperative recovery after scheduled compared to unplanned cesarean delivery: a retrospective chart review

BackgroundStudies examining the effects of various analgesics and anesthetics on postoperative pain following cesarean delivery conventionally use the scheduled cesarean population. This study compares postoperative analgesic requirements and recovery profiles in women undergoing scheduled cesarean compared to unplanned cesarean delivery following labor. We postulated that unplanned cesarean deliveries may increase postoperative analgesic requirements.MethodsWe conducted a retrospective chart review of 200 cesarean deliveries at Lucile Packard Children’s Hospital, California. We examined the records of 100 patients who underwent scheduled cesarean delivery under spinal anesthesia (hyperbaric bupivacaine 12 mg with intrathecal fentanyl 10 μg and morphine 200 μg) and 100 patients that following a trail of labor required unplanned cesarean under epidural anesthesia (10–25 mL 2% lidocaine top-up with epidural morphine 4 mg after clamping of the umbilical cord). We recorded pain scores, analgesic consumption, time to first analgesic request, side effects, and length of hospital stay.ResultsWe found no differences in postoperative pain scores and analgesic consumption between scheduled and unplanned cesarean deliveries for up to five days postoperatively. There were no differences in treatment of side effects such as nausea, vomiting, or pruritus (P > 0.05).ConclusionThe results indicate that women experience similar pain and analgesic requirements after scheduled compared to unplanned cesarean delivery. This suggests that the non-scheduled cesarean population may be a suitable pain model to study pain management strategies; and that alterations in pain management are not necessary for the unplanned cesarean delivery population.     

Postcesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac

STUDY OBJECTIVE: To assess the analgesic efficacy of diclofenac when administered as an adjuvant to bupivacaine wound instillation. DESIGN: Prospective, randomized, double blind, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: 90 women recovering from cesarean delivery performed via a Pfannenstiel incision. INTERVENTIONS: A standard intrathecal anesthetic was administered. On completion of surgery, a multiorifice 20-gauge epidural catheter was placed within the surgical wound. Postoperatively, the catheter was attached to a patient-controlled analgesia (PCA) device programmed to deliver 9 mL with a 60-minute lockout time and no basal infusion. In group bupivacaine-diclofenac, the PCA device delivered 0.25% bupivacaine, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline). Thereafter, oral diclofenac (50 mg) was administered every 8 hours. In group bupivacaine-placebo, 0.25% bupivacaine and an equal volume of intravenous saline or oral placebo were administered 20 minutes before the end of surgery and every 8 hours thereafter. In group placebo-diclofenac, wound instillation was with sterile water, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline) and thereafter oral diclofenac (50 mg) at 8-hour intervals. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, intravenously). Thereafter, subcutaneous morphine (0.05 mg/kg) was administered on patient request for additional analgesia. MEASUREMENTS AND MAIN RESULTS: The number of attempts to activate the PCA device was significantly higher in group bupivacaine-placebo (39 +/- 32) when compared with group bupivacaine-diclofenac (24 +/- 28). During the first 6 postoperative hours, the number of patients requiring rescue morphine and the total rescue morphine administered were significantly different between the groups. During the subsequent 18 hours, subcutaneous morphine administration was significantly higher in group bupivacaine-placebo. Postoperative pain scores were significantly higher in group bupivacaine-placebo when compared with those recorded in groups placebo-diclofenac and bupivacaine-diclofenac. Finally, patient satisfaction was significantly lower in group bupivacaine-placebo. CONCLUSION: In the context of this study, the bupivacaine wound instillation with adjuvant diclofenac administration is associated with similar postoperative analgesia to that induced by diclofenac alone.     

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: A randomized,placebo-controlled trial

Study objectiveThe aim of this study was to evaluate the effect of ultrasound-guided erector spinae plane (ESP) block on postoperative pain in radical prostatectomy, which leads to both visceral and somatic pain.DesignProspective, randomized, placebo controlled, double-blinded.SettingUniversity hospital.PatientsA total of ASA I-III, 50 patients aged 18–65 who were scheduled for elective open radical prostatectomy surgery.InterventionsPatients were randomly allocated to receive an ultrasound-guided ESP block, with either local anesthetic (10 mL of 1% lidocaine +10 mL of 0.5% bupivacaine) or placebo bilaterally.MeasurementsThe primary outcome was morphine consumption in the first 24 h after surgery. The secondary outcomes were NRS pain scores at rest and coughing, intraoperative remifentanil consumption and need for rescue analgesic during the first 24 h after surgery.Main resultsBoth NRS scores for post-anesthesia care unit and NRS_rest scores for 1st hours were lower in Group ESPB (p < 0.001 and p = 0.033, respectively). Cumulative morphine consumption at 24 h post-surgery was similar between the groups (p = 0.447). Rescue analgesic requirement was higher in the placebo injection group than in the ESPB group at the 1st postoperative hour (p = 0.002).ConclusionsIn open radical prostatectomies, except for the first hour, ESP block is ineffective for pain scores and on morphine consumption compared to the placebo injection group in the postoperative period.     

Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section

ObjectiveNowadays, conventional analgesic agents, which are widely used for pain relief after cesarean section, provide suboptimal analgesia with occasional serious side effects. We designed a randomized, double-blind, placebo-controlled study to evaluate the analgesic efficacy of intrathecal ketamine added to bupivacaine after cesarean section.MethodsSixty patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the two groups to receive either bupivacaine 10 mg combined with 0.1 mg/kg ketamine, or bupivacaine 10 mg combined with 0.5 mL distilled water intrathecally. The time to the first analgesic request, analgesic requirement in the first 24 hours after surgery, onset times of sensory and motor blockades, the durations of sensory and motor blockades, and the incidences of adverse effects such as hypotension, ephedrine requirement, bradycardia, and hypoxemia, were recorded.ResultsPatients who received ketamine had a significantly prolonged duration of anesthesia compared with those who did not in the control group [95% confidence intervals (CI) 195–217; p = 0.001]. The mean time to the first analgesic request was also significantly longer in ketamine group (95% CI 252.5–275; p < 0.001). The total analgesic consumption in the 24 hours following surgery significantly lessened in the ketamine group compared with that of the control group (95% CI 2–2.5; p < 0.001). The two groups did not differ significantly in intraoperative and postoperative side effects.ConclusionIntrathecal ketamine 0.1 mg/kg co-administered with spinal bupivacaine elongated the time to the first analgesic request and lessened the total analgesic consumption in the first 24 postoperative hours in comparison with bupivacaine alone in the control group following elective cesarean delivery.     

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundNerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA.MethodsIn this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB + sham AQLB (SFIB group), or an ultrasound-guided AQLB + sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24 hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications.ResultsThere were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .774), the time to first rescue analgesia (P = .890), the time to hospital discharge (P = .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2 hours (P = .008) and 6 hours (P = .009) after surgery.ConclusionUnder the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6 hours after surgery.     

Comparing the effectiveness of ropivacaine 0.5% versus ropivacaine 0.2% for transabdominis plane block in providing postoperative analgesia after appendectomy

ObjectiveThe basis for the transversus abdominis plane (TAP) block involves infiltration of a local anesthetic into the neurofascial plane between the internal oblique and the transversus abdominis muscles, causing a regional block that spreads between the L1 and T10 dermatomes. Thus, the TAP block is said to be suitable for lower abdominal surgery. This study was designed to compare the analgesic efficacy of two different concentrations of ropivacaine for TAP block in patients undergoing appendectomy.MethodsFifty-six patients with American Society of Anesthesiologists physical status I or II, aged 18 years and above, undergoing appendectomy were recruited in this prospective, randomized, double-blind study. They were divided into two groups: Group A patients who received 0.5 mL/kg of ropivacaine 0.5% and Group B patients who received 0.5 mL/kg of ropivacaine 0.2% via TAP block under ultrasound guidance. Postoperative pain was assessed using the visual analog scale upon arrival at the recovery room in the operating theatre, just prior to being discharged to the ward, and at 6 hours, 12 hours, 18 hours, and 24 hours postoperatively to compare the effectiveness of analgesia.ResultsIntraoperatively, patients in Group B required a significantly greater amount of additional intravenous fentanyl than those in Group A. There were no significant statistical differences in pain scores at rest and on movement at all assessment times as well as in the dose of 24-hour intravenous morphine consumption given via patient-controlled analgesia postoperatively between the two groups.ConclusionThe effectiveness of two different concentrations of ropivacaine (0.5% versus 0.2%) given via TAP block was comparable in providing postoperative analgesia for patients undergoing appendectomy.     

Comparison of Analgesic Efficacies of the iPACK (Interspace Between the Popliteal Artery and Capsule of the Posterior Knee) and Genicular Nerve Blocks Used in Combination With the Continuous Adductor Canal Block After Total Knee Arthroplasty: A Randomized Clinical Trial

BackgroundThe interspace between the popliteal artery and capsule of the posterior knee (iPACK) block and the genicular nerve block (GNB) are motor-sparing nerve blocks used for knee pain relief. We compared the analgesic efficacies of ultrasound-guided iPACK block and GNB when combined with continuous adductor canal block after total knee arthroplasty.MethodsIn this randomized control study, 132 total knee arthroplasty patients were assigned to the iPACK, GNB, and iPACK + GNB groups. All patients received combined spinal anesthesia and continuous adductor canal block. The primary outcome was the 8-hour postoperative pain score during movement. Secondary outcomes were pain scores, posterior knee pain, intravenous morphine consumption, and tibial and common peroneal nerve sensorimotor function. All included patients completed the study.ResultsThe 4-hour and 8-hour postoperative pain scores during movement were significantly lower in the iPACK + GNB group than that in the iPACK group (−2.5 [3.6, 1.3]; P < .001 and −2 [-3, −1]; P < .001, respectively). The differences in rating pain scores and posterior knee pain were not clinically relevant. The iPACK group demonstrated a significantly higher intravenous morphine consumption than did the GNB and iPACK + GNB groups during the first 48 hours postoperatively (P < .001) but were not clinically relevant. There was no incidence of complete sensorimotor blockade in any of the groups.ConclusionThe iPACK–GNB combination relieved pain during movement better than the iPACK block alone during the 8 hours postoperatively after total knee arthroplasty in setting of multimodal analgesia such as adductor canal block.     

Intravenous Dexamethasone Injection Reduces Pain From 12 to 21 Hours After Total Knee Arthroplasty: A Double-Blind,Randomized, Placebo-Controlled Trial

BackgroundPain after total knee arthroplasty (TKA) affects postoperative recovery and patient satisfaction. The analgesic benefits of corticosteroids have not been well studied. We, therefore, investigated the analgesic effects of intravenous (IV) dexamethasone (DEX) in patients undergoing a TKA.MethodsThis was a randomized, double-blind, placebo-controlled trial of 0.15 mg/kg of IV DEX vs saline placebo in unilateral TKA. Fifty patients/arm were recruited. Primary outcomes were pain level, determined by a visual analog scale, and the amount of morphine consumption (mg) ≤48 hours post-TKA. Secondary outcomes were rates of nausea and vomiting, C-reactive protein concentrations, and functional outcomes.ResultsThe DEX group had a significantly lower mean visual analog scale score both at rest and during motion at 12, 15, 18, and 21 hours (P < .05). At 21 hours, the mean difference (Δ) in pain at rest was −11 points (95% confidence interval [CI], −21 to −2 points; P = .02) while the mean difference in pain during motion was −15 points (95% CI, −25 to −5 points; P = .004). The DEX group also had lower rates of nausea and vomiting: 29/50 (58%) vs 42/50 (84%) (P = .008) and lower mean C-reactive protein level: 89 vs 167, Δ = −78 mg/L (95% CI, −100 to −58 mg/L, P < .0001). There were no significant differences in mean morphine consumption by 48 hours, modified Western Ontario and McMaster University Osteoarthritis Index scores, and range of motion of the knee at 3-month follow-up (P > .05).ConclusionIV DEX relieves postoperative pain between 12 to 21 hours after TKA and may be a useful adjunct for controlling pain in patients undergoing TKA.     

Combined use of intrathecal morphine and diclofenac suppository for postoperative analgesia after caesarean section

BACKGROUND: Intrathecal morphine for postoperative analgesia after caesarean section has been used in Europe and North America, but its use is not common in Japan. METHODS: We randomized 40 parturients to two groups, given either intrathecal saline (control group) or intrathecal morphine 0.05 mg (morphine group) for caesarean section. To both groups, we gave a diclofenac suppository 50 mg every 8 hours after surgery. RESULTS: The area under curve for the visual analogue scale for pain during 24 hours after operation was significantly lower (P < 0.01) in the morphine group than the control group. In addition, the parturients who required pentazocine as a rescue analgesia was significantly fewer in the morphine group (5 parturients) than the control group (11 parturients). There was no significant difference between the two groups in the Apgar score of infants, pH in umbilical cord arterial and venous blood and the incidence of postoperative nausea and vomiting. The incidence of pruritus was significantly higher in the morphine group (11 parturients) than the control group (no parturient). CONCLUSIONS: Intrathecal morphine 0.05 mg and diclofenac suppository 50 mg given every 8 hours produced effective postoperative analgesia with minimum side effects after caesarean section.     

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundOne of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam’s analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.MethodsWe conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.ResultsPatients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.ConclusionContinuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.Level of EvidenceTherapeutic Level I.     

Post-cesarean gabapentin is not associated with lower opioid consumption or pain scores in women on chronic buprenorphine therapy: A 10-year retrospective cohort study

Study objectiveTo determine if postoperative gabapentin administration is associated with decreased opioid consumption or pain scores following cesarean delivery in women on chronic buprenorphine.DesignRetrospective cohort study.SettingPostoperative recovery area and postpartum inpatient unit.Patients214 women undergoing cesarean delivery while on chronic buprenorphine at a single institution between 2007 and 2017.InterventionsGabapentin treatment for post-cesarean analgesia.MeasurementsThe primary outcome was opioid consumption in morphine milligram equivalents, comparing patients who received ≥1 dose of gabapentin within 24 h of cesarean delivery to those who did not. Secondary outcomes included opioid consumption 24–48 and 48–72 h post-cesarean and postoperative numerical rating scale pain scores.Main resultsOf 214 included patients, 64 (30%) received gabapentin while 150 (70%) did not. Gabapentin patients were more likely than controls to have received neuraxial fentanyl (30% vs. 14%, p = 0.01) and transversus abdominis plane block (6% vs. 1%, p = 0.05) and overall received higher doses of ketorolac and acetaminophen. Control patients were more likely to have received neuraxial morphine (78% vs. 90%, p = 0.04) and received higher doses of ibuprofen. In unadjusted analysis, there was no significant difference in morphine milligram equivalent consumption 0–24 h postoperatively between gabapentin (55 mg [IQR 26,84]) and control (53 mg [IQR 28,75]) groups (p = 0.38). After controlling for potential confounders, there remained no significant effect of gabapentin administration (overall effect p = 0.99). Opioid consumption and pain scores were also not significantly different at any other time points.ConclusionsIn parturients receiving chronic buprenorphine, inclusion of gabapentin in a multimodal analgesic regimen was not associated with lower opioid consumption or pain scores during the first 72 h after cesarean delivery. Prospective randomized studies are needed to confirm these findings.